Renewal Application

ENDORSED BY THE AMERICAN LAND TITLE ASSOCIATION
NOTICE:

A policy may be issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your state. State guaranty funds are not available for your risk retention group. The insurance coverage for which you are applying is written on a CLAIMS MADE AND REPORTED policy. Therefore, only claims which are first made against the Insured and reported during the policy period are covered, subject to policy terms, exclusions, and conditions including the notice of claim conditions of the policy. "Claim" means a demand for money or services, alleging a wrongful act by the Insured, including the service of suit or institution of arbitration proceedings.
INSTRUCTIONS:

Please answer all questions completely. This form must be completed, signed, and currently dated by an owner, member, principal, or officer of the firm applying for coverage. ACTIVE MEMBERSHIP IN THE AMERICAN LAND TITLE ASSOCIATION (ALTA) IS REQUIRED TO RENEW THIS COVERAGE.
1. Name of Applicant/Firm (include ALL firm names, trading names, or DBA's under which Applicant operates:*
Street Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address if different from Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
2. Additional Offices/Locations*

YESNO
Additional Offices/Locations (list complete address):
3. List ALL states where Applicant operates:*
4. Have there been any changes in the firm's organization, ownership, or operations since last year?*

YESNO
If YES, please provide a detailed explanation
5. Applicant's business activities:*

TITLE AGENTABSTRACTER/SEARCHERESCROW/CLOSINGOTHER (PROVIDE DESCRIPTION BELOW)

6. If the Applicant's activities include acting as a title agent, please list the title insurer(s) with whom the firm has agency contracts and the approximate percent of title insurance premium written with each:
7. OWNERS AND STAFF (count each person only once):
a. All owners, officers, and employees engaged on a full or part-time basis in one or more of the following activities: abstracting, searching, title underwriting, title opinion, escrow/closing services, commitment or policy preparation/production:*
b. State the name, activities and years of experience for each owner/staff member:*
c. Of the number in 7a, how many are part-time (less than 20 hours per week)?*
d. Are independent contractors hired to search titles or to perform closings or other services?

YESNO
e. If YES to 7d, do independent contractors maintain their own E&O insurance?*

YESNO
f. What percentage of Applicant's business is performed by independent contractors?
Enter percentage
Describe services performed by independent contractors if applicable:

8. GROSS REVENUE: show all revenue, fees and commissions before deduction of expenses. *

	Past Fiscal Year Ending	Next 12 Months (Estimated)
a. Title Agency Commissions (NOT Premiums)
b. Abstracting/Searching Fees
c. Escrow/Closing/Witness Closing Fees
d. Other Services (please describe services and revenue from each service on a sheet)
e. Total Gross Revenue from all Sources

12. After inquiry of all persons identified in response to question 7.a., during the past year, has any claim been made or are there any circumstances which may result in a claim that have NOT BEEN REPORTED to TIAC?*

YESNO
If YES, please explain on a separate sheet. NOTE: Any claim arising from an wrongful act, error, omission, circumstance, fact or situation required to disclosed in response to Questions 12 is EXCLUDED from coverage under the proposed insurance.
13. During the past year, has the Applicant or any person identified in response to questions 7.a. had an agency agreement terminated, a license revoked or suspended, or been formally reprimanded or subject to disciplinary action?*

YESNO
If YES, please provide detailed description.

I/We hereby warrant, after inquiry of all persons identified in response to question 4, that the above statements and particulars are true and that I/we have not suppressed or misstated facts. I/we agree that this Application, including any attachments, shall be deemed to be material to the risk assumed by TIAC; shall be the basis of the contract with TIAC; and that any policy issued may be affected by any suppressed or misstatement. It is understood and agreed that this Application forms a part of any policy issued by TIAC to the Applicant and shall be deemed to be attached to and form a part of the policy. It is understood and agreed that completion of this Application does not bind TIAC to issue not the Application to purchase any policy.

If thre is any significant change in the operations of the Applicant, or if any information supplied in the Application or any attachement to this Application changes between the date of the Application and the policy inception date, which would render this Application or any attachment to this Application inaccurate or incomplete, the Applicant agrees to provide immediate notice in writing to TIAC of any such change.

Any material misrepresentation or concealment in apply for this policy or in pursuing a claim under this policy shall be deemed ground for denial of coverage and/or cancellation or recission of this policy.
Name and Title of Applicant *
Signature of Applicant *

Clear

ENDORSED BY THE AMERICAN LAND TITLE ASSOCIATION

NOTICE:

INSTRUCTIONS:

PRIVACY BREACH AND CLIENT FUNDS PROTECTION COVERAGE SUPPLEMENTAL APPLICATION